Showing posts with label surgery. Show all posts
Showing posts with label surgery. Show all posts

Thursday, October 30, 2014

For Treating Empyema, Which Is Better—Urokinase Drainage or Video-Assisted Thoracoscopy?

By: Lewis First, MD, MS; Editor-in-Chief 

Video-assisted thoracoscopy.
Image by Cancer Research UK  via Wikimedia Commons.
Every once in a while we have a patient who develops a parapneumonic effusion of pus (otherwise known as an empyema) as a complication of an acute bacterial pneumonia. When this happens, treatment might involve a chest tube and when that fails, the use of thoracoscopy.

Recently however, the addition of urokinase to enzymatically break apart the empyema has been suggested to make the chest-tube drainage method more effective—but is it as effective as video-assisted thoracoscopy (VATS)?

Marhuenda et al. (doi:10.1542/peds.2013-3935) approached this question by performing a prospective randomized multicenter clinical trial in children younger than 15 years old with empyema that required intervention.

The results indicate that urokinase plus drainage may be just as effective as VATS, but if you want to see for yourself, scope out this study and discuss it with your local pediatric surgeons to see if they agree the two treatments are similar. Be sure to share what you learn with us by leaving a comment here on the blog, sharing an eLetter on our journal’s website or visiting us on Facebook or Twitter.

Related Reading:

Thursday, March 13, 2014

What Does a Quarter Century of Doing Pediatric Kidney Transplants Tell Us?

Kidney transplants have been performed in this country for decades now, and one wonders whether outcome data has been improving, worsening or staying the same as the years go by.

Photo by Hey Paul Studios via Flickr
Van Arendonk et al. (doi: 10.1542/ peds.2013-2775) opted to look back on 25 years of kidney transplant
outcomes and look at graft survival statistics based on the characteristics of donors and recipients. The trends in improved outcomes are quite impressive so take a peek at this detailed look at graft and patient outcomes and the multiple logistic regression analysis that identifies risk factors for prognosis. With more than 17,400 pediatric kidney-only transplants performed from 1987 to 2012, there’s much to be learned from the large data set included in this study.

In fact, as positive as the outcome trends are over the years, there is still more that can be done to further improve these trends, and Dr. Uptal Patel shares his thoughts on just what’s next in renal transplantation in an accompanying commentary (doi: 10.1542/peds.2013-0124). Read this interesting study and commentary and see what we mean.

Related Reading:

Wednesday, January 22, 2014

Variations in Tonsillectomy Perioperative Complications and Revisit Rates May Be Tough Ones to Swallow

Tonsillectomy might seem like a fairly standard operation for those of us who do not perform this procedure, but Mahant et al. (doi: 10.1542/peds.2013-1884) convince us otherwise in a retrospective cohort study of low-risk children who underwent this operation at 36 US hospitals over a seven year
period (2004-2010).

Public Domain photo via Wikimedia Commons
The authors looked at the quality of care as measured by deviations from evidence-based protocols based on national guidelines, including the use of perioperative dexamethasone and no antibiotic usage, as well as by revisit rates to the same hospital for bleeding and dehydration.

Despite the hard work done to date to evidence-base how this operation should be performed, this article will reveal that substantial variation still exists and warrants our designing a better strategy to educate those hospitals who vary the most from standard operating protocol.

There’s more than a mouthful of findings to talk and do something about contained in this study, so if you do plan to send your patient for this operation, you’d do well to give this article some attention.

Thursday, January 16, 2014

Otitis Media with Effusion: A Systematic Review Looks at the Value Added of Various Surgical Treatments

Dealing with recurrent or chronic otitis media with effusion has certainly been a topic for many clinical investigators over the years. Which approach (myringotomy, typanostomy tubes, adenoidectomy, or simply observing is best when it comes to duration of the effusion and ability to hear in the short run? Which, if any, of these approaches results in improvement in the long run in language, cognitive or other academic outcomes?

Photo by tpsdave via Pixabay
Wallace et al. (doi: 10.1542/peds.2013-3228) have taken the time to systematically compile 41 studies involving randomized and nonrandomized controlled trials, as well as cohort studies, to produce a systematic review
that makes sense of
the data and evidence already published
in a way that can be helpful to you and your patients’ families who are asking for the best way to deal with this common ear problem. The results of aggregating these studies are worth not just hearing about, but reading and discussing with colleagues as well as your patients.

Is there a definitive answer? We’re all ears to hear what you think –so share your thoughts on this analysis by responding to this blog, through Facebook and Twitter, or submit an eLetter to the authors.

Friday, January 3, 2014

Using the White Blood Cell Count to Reduce Negative Appendectomies: A Retrospective Study

Yesterday, we blogged about using a clinical pathway to predict suspected appendicitis, and today, we continue our discussion of appendicitis and ways to minimize negative appendectomies.

While surgeons may tell you they need to operate on a presumptive appendix even if that appendix may not be inflamed, so as not to miss a potential perforation, they will also want to minimize the negative appendectomy rate. Yet how can they do this?

Bates et al. (doi: 10.1542/peds.2013-2418) decided to see if the magnitude of the white blood cell count (in this case a lower one) could defer surgery and increase observation before automatically operating on a child with a presumptive acute abdomen. The authors did a retrospective review of all appendectomies performed over a 42 month period of time and looked at pre-op lab and radiographic data for all patients in this study. The authors compared this data for normal and abnormal appendices and found normal white blood cell counts (below 8,000 - 9,000) meant a reduction in negative appendectomies.

Just how much of a reduction requires you to cut into this study and decide how much you trust the results to stop surgery or at least observe longer in the setting of a low- normal white blood cell count.

Related Reading:

Thursday, January 2, 2014

Using a Clinical Pathway to Predict Accurately a Suspected Appendicitis: A Prospective Study

In a quest to figure out the most accurate way to diagnose an acute appendix, Saucier et al. (doi: 10.1542/peds.2013-2208) designed a clinical pathway that used a known pediatric appendix score and an ultrasound study to classify patients as low-, middle-, and high-risk for appendicitis –with the low-risk being sent home in this prospective cohort, the middle- group getting an ultrasound, and the high-risk getting operated upon.

So how good is this new guideline? Good enough to carry a high sensitivity and specificity for accurate diagnosis of appendicitis. Just thinking that an ultrasound can be used in place of a CT scan to make this diagnosis is a concept that is certain to radiate positively within all of us.

Stay tuned-- tomorrow we continue our discussion on the appendix with a look at a study that uses white blood cell count to reduce the rate of negative appendectomies.

Wednesday, November 27, 2013

A Study at the Cutting Edge: Variations in Pediatric Surgical Procedures in the US

Photo by TPSDave via Pixabay
Surgery on children is done nationwide—but not always in a children’s hospital. Just what kinds of pediatric operations are occurring in adult general hospitals that also care for children and how different are they from ones performed in free-standing children’s hospitals? Does geographic region of the country determine who is doing what type of operation—be it a pediatric or general surgeon, and how might this influence outcomes as well as workforce distribution of pediatric surgeons and future trainees?  

Somme et al. (doi: peds.10.1542/2013-1243) share the output from a large pediatric database for patients under 18 years that allowed calculation of surgical frequencies for a myriad of different operations—in fact, there were more than 216,000 in the database for 2009. Barnhart et al. (doi: peds.10.1542/2013-3154), including Dr. Rebecka Meyers, a member of our editorial board, help shed some light on the findings in this study as they might affect surgical care to our patients. Make an incision into this study and commentary and learn more.